Failure to Adhere to Enhanced Barrier Precautions and Equipment Sanitization
Penalty
Summary
Staff failed to adhere to Enhanced Barrier Precautions (EBP) guidelines for two residents with high-risk conditions. For one resident with a history of cerebral vascular accident, diabetes, COPD, and a gastrostomy tube, a Certified Nursing Assistant (CNA) entered the room multiple times to provide care and use a sit-to-stand lift without donning a gown, as required by EBP policy. The CNA also failed to sanitize the lift after use. Interviews revealed confusion among staff regarding the necessity of wearing gowns for residents with gastrostomy tubes, even when not in use, and the expectation to sanitize equipment after each use. For another resident with late-onset Alzheimer's disease and a stage IV sacral pressure ulcer, there was no Personal Protective Equipment (PPE) cart outside the room during one observation, and a Hospice CNA provided direct care, including bathing and linen changes, without donning PPE as indicated by EBP signage. The Hospice CNA was unaware that the resident was on EBP, citing a lack of communication from the facility. The PPE cart was later replaced, but it was confirmed that it had been missing on previous days. Interviews with facility staff, including an LPN and the Infection Control Preventionist (ICP), confirmed that both residents were on EBP due to their medical conditions and that staff were expected to use gowns and gloves during care and to sanitize equipment after use. The ICP acknowledged the lapses in communication and adherence to EBP protocols, including the failure to inform Hospice staff and ensure PPE availability.